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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604814
Report Date: 12/06/2023
Date Signed: 12/06/2023 01:17:18 PM

Document Has Been Signed on 12/06/2023 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMAZING GRACE HOME CENTERFACILITY NUMBER:
197604814
ADMINISTRATOR:GRACE O. BAJOMOFACILITY TYPE:
735
ADDRESS:8732 DEBRA AVENUETELEPHONE:
(818) 895-6332
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 3DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Grace Bajomo, Administrator TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Angela Panushkina conducted an Annual Required visit and inspection of the facility. LPA met with administrator, Grace Oyebobola, and explained the reason for the visit.

At 10:35am, with the assistance of the Administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored under the kitchen sink and LPA observed it was locked and inaccessible to clients in care. The fire extinguisher is located in the kitchen, and was last serviced on 05/22/2023. The laundry is located in a kitchen closet. At 10:42am, a carbon monoxide detector located in the kitchen was tested and observed to be functional. Properly labeled medications were locked in one of the dining room cabinets.

Bedrooms: Facility has four (4) bedrooms of which thee (3) are designated for clients use and one bedroom for the staff. All four of bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: Facility has two (2) bathrooms. During the tour at 10:45am, LPA observed the bottom of a bathroom vanity had a hole (where pipes come out), due to water damage. LPA was informed that the water leak occurred on 12/04/23. Hot water temperature was tested at 115.1°F.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The smoke alarms are hardwired and interconnected and at 11:00am were tested and observed to be functional.
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMAZING GRACE HOME CENTER
FACILITY NUMBER: 197604814
VISIT DATE: 12/06/2023
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. LPA observed an empty pool was surrounded with a fence, at least five-feet high, and was locked and inaccessible to clients in care.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2023 01:17 PM - It Cannot Be Edited


Created By: Angela Panushkina On 12/06/2023 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING GRACE HOME CENTER
FACILITY NUMBER: 197604814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above by having a hole underneath a bathroom vanity (where pipes come out), due to water damage which occurred on 12/4/23, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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Licensee/Administrator will hire a professional to fix/repair a hole/cut underneath the bathroom vanity. Proof of invoce/picture shall be submitted to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
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